Cross-Country Differences in Self-Rated Health: Decomposing the Influence of Depressive Symptoms

Background: Despite extensive research on self-rated health (SRH), the extent to which mental health is a component part of SRH assessments and whether this relationship varies by country remains underexplored. This study quantifies the contribution of depressive symptoms to self-rated health and assesses cross-national variation in this association. Methods: Using general population data from older adults (age 55 years+) in 18 countries in the Survey of Health, Ageing and Retirement in Europe (SHARE, 2011-2015), we employed four approaches: (1) country-specific pseudo R-square models assessing the contribution of depressive symptoms (EURO-D) to SRH, adjusting for socio-demographics, physical health, and functional limitations; (2) partial correlation networks to visualize relationships between SRH, depressive symptoms, and physical health indicators; (3) Blinder-Oaxaca decompositions to quantify cross-country differences in SRH attributable to depressive symptoms and (4) stratification of the estimates by gender. Results: Depressive symptoms explained nearly as much variance in SRH as physical health. Partial correlation networks revealed SRH as central to all health measures, and correlations with depressive symptoms ranging from 0.15 (Israel) to 0.35 (Hungary). Decomposition analyses identified three distinct patterns: Nordic countries (e.g., Denmark, Sweden) had lower depression prevalence but stronger depression-SRH associations, Eastern European countries (e.g., Estonia, Hungary) showed lower depression levels but weaker depression-SRH associations, and Mediterranean countries (e.g., Greece, Spain) exhibited higher depressive symptoms prevalence but weaker depression-SRH associations. Gender disparities in SRH were largely explained by differences in depressive symptom levels rather than differential weighting of depressive symptoms in self-assessments. Discussion: Depressive symptoms contribute to self-rated health independently of physical health, confirming that mental health is integral to how individuals perceive their health. However, the extent to which this is the case varies cross-nationally highlighting that the meaning of health is shaped by national and cultural contexts and this should be considered in any within-country or cross-national research using self-rated health measures.